Medicare payments constitute a significant share of patient-generated revenues for rural providers, more so than for urban providers. Therefore, Medicare payment policies influence the behavior of rural providers and determine their financial viability. Health services researchers need to contribute to the understanding of the implications of changes in fee-for-service payment policy, prospects for change because of the payment to Medicare+Choice risk plans, and implications for rural providers inherent in any restructuring of the Medicare program. This article outlines the basic policy choices, implications for rural providers and Medicare beneficiaries, impacts of existing research, and suggestions for further research. Topics for further research include implications of the Critical Access Hospital program, understanding how changes in payment to rural hospitals affect patient care, developing improved formulas for paying rural hospitals, determining the payment-to-cost ratio for physicians, measuring the impact of changes in the payment methodology used to pay for services delivered by rural health clinics and federally qualified health centers, accounting for the reasons for differences in historical Medicare expenditures across rural counties and between rural and urban counties, explicating all reasons for Medicare+Choice plans withdrawing from some rural areas and entering others, measuring the rural impact of proposals to add a prescription drug benefit to the Medicare program, and measuring the impact of Medicare payment policies on rural economies.

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PubMed2002

Racial and ethnic differences in health insurance for the near elderly.

Recent increases in the number of Americans without health insurance have spurred research designed to identify factors related to noncoverage. One age group receiving recent attention is the near elderly, persons 55 through 64 years of age. This paper brings together health insurance research on the near elderly with that focused on racial and ethnic differences in coverage. Logistic regression is used to study the factors that predict whether or not an individual has health insurance coverage. Results indicate that even after accounting for health insurance correlates such as education and income, non-Hispanic African Americans and Hispanics have a significantly higher probability of not having coverage than their non-Hispanic white counterparts. The results are discussed in terms of recent efforts to reshape public policy regarding health insurance, especially proposals that would affect the Medicare program.

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PubMedDate not supplied

Comprehensive evaluation of a community coalition: a case study of environmental tobacco smoke reduction.

Community coalitions have become an increasingly popular means for addressing community health issues, yet evaluating their effectiveness and performance has presented formidable challenges. To meet the community's need for health program evaluation, public health nurses will need to become better prepared to deal with the complexities of evaluating coalitions and their multifaceted organizational structures. This article presents the methodology and conceptual framework, Targeting Outcomes of Programs (TOP), used to evaluate the performance and impact of a local community coalition. The case study offered here focuses on a tobacco-prevention coalition composed of 15 public and private agencies and their 121 activities. The TOP evaluation model provided the coalition with formative evaluation, needed to improve the coalition's on-going program delivery, and summative evaluation, needed for annual reviews of the coalition's effectiveness and impact in the community. The methodological approach and instrument presented here provide the public health nurse with a solid conceptual framework for approaching such a task.

Community Health Planning↗